[Neurosarcoidosis. Comparative analysis of the clinical profile based on 537 cases from the world literature up to 1963 and from 1976-1988]

Challenges in the diagnosis and treatment of neurosarcoidosis

The diagnosis and treatment of neurosarcoidosis can be very challenging for several reasons. It affects clinically 5%-10% of sarcoidosis patients, but can be found in up to 25% of autopsies. These data reveal that a high percentage of asymptomatic or misdiagnosed cases can be missed at an initial diagnostic approach. Clinical and imaging findings are often non-specific since they can be found in a large number of neurological disorders. Histopathology can also be confounding if not performed by an expert pathologist and not placed in an appropriate clinical context. In this review, we discuss clinical features, laboratory findings, imaging, and histology of neurosarcoidosis, and we report current evidence regarding drug therapy. We conclude that a correct diagnostic approach should include a multidisciplinary evaluation involving clinicians, radiologists, and pathologists and that future studies should evaluate the genetic signature of neurosarcoidosis as they could be helpful in the assessment of this uncommon disease. With head-to-head comparisons of medical treatment for neurosarcoidosis still lacking due to the rarity of the disease and an increasing number of immunomodulating therapies at hand, novel therapeutic approaches are to be expected within the next few years.

Bilateral Vestibular Hypofunction in Neurosarcoidosis: A Case Report

We describe the case of a 59-year-old woman who presented with progressive bilateral vestibidar hypofunction and who was found to have bilateral granulomatous mass lesions of the mesial temporal lobe. Initially, her condition stabilized neurologically with corticosteroids, but a diagnosis of neurosarcoidosis was delayed because of the unusual presentation and persistently normal chest imaging results and serum angiotensin-converting enzyme (ACE) levels. Approximately 1 year after her initial presentation, the patient died of complications of a myocardial infarction and pulmonary embolism. Sarcoidosis should be considered in the differential diagnosis of idiopathic bilateral vestibular hypofunction even if the chest imaging and serum ACE levels are normal, particularly when there is evidence of a multisystem process.

Endocrine aspects of neurosarcoidosis

The involvement of the hypothalamus and/or pituitary gland by granulomatous, infiltrative or autoimmune diseases is a rare condition of non-tumoral-non-vascular acquired hypothalamic dysfunction and hypopituitarism. In this paper, we present the case of a 26-year-old woman, who showed an amenorrhea-galactorrhea syndrome with hypogonadotropic hypogonadism due to an isolated hypothalamic-peduncular localization of neurosarcoidosis. Acquired GH deficiency was also demonstrated. This clinical case provided the opportunity for a review of the endocrine aspects linked to brain infiltrative diseases that may affect the hypothalamic-pituitary function, with a focus upon neurosarcoidosis. Sarcoidosis is a pathogen-free granulomatous disease that affects both the central and peripheral nervous system in 5-16% of patients. In most cases, such involvement by sarcoidosis occurs within a multi-systemic disease, but disease localization limited to the nervous system may also be observed. Endocrine manifestations of neurosarcoidosis disclose "chameleon-like" clinical pictures, which are usually expressed by the evidence of hypothalamic dysfunction, diabetes insipidus, adenopituitary failure, amenorrhea-galactorrhea syndrome, in isolated fashion or variedly combined. More rarely, inappropriate anti-diuretic hormone secretion, isolated secondary hypothyroidism, adrenal insufficiency or altered counter-regulation of glucose homeostasis have been reported. Neurosarcoidosis is often hard to diagnose, especially when the neurological localization of the disease is not accompanied by other systemic localizations or by specific signs of the disease, and when the lesion is too deep to obtain bioptic confirmation. The study of cerebrospinal fluid and blood lymphocyte sub-populations, integrated by MRI and nuclear scans (67GalIium uptake and 111Indium-pentetreotide, Octreoscan), may be helpful for a correct diagnosis. Therapy with corticosteroid and immunosuppressive drugs, such as cyclosporine A, and other treatment approaches to neurosarcoidosis are also accounted for.

Diagnosis and management of neurosarcoidosis

Sarcoidosis is a multisystemic disorder characterised by the presence of multiple noncaseating granulomas. Clinically recognisable nervous system involvement occurs in 5-16% of patients with sarcoidosis. However, the incidence of subclinical neurosarcoidosis may be higher. The following article presents a review of the disease, including its pathophysiology, clinical and radiological characteristics and treatment. Neurosarcoidosis should be included in the differential diagnosis of infectious and noninfectious neurological syndromes.

Neurosarcoidosis without systemic sarcoidosis

Neurosarcoidosis is a well-recognised complication of systemic sarcoidosis but diagnosis may be difficult if there is no clear evidence of an extracerebral manifestation of the disease. We present the case of a 42-year-old woman with clinical features characteristic of cerebral sarcoidosis including tetraparesis, diabetes insipidus, diencephalic hyperphagia, personality changes, and memory loss. Diagnosis was supported by cerebrospinal fluid (CSF) findings and magnetic resonance imaging (MRI): CSF showed mild lymphocytic pleocytosis, intrathecal production of IgG without oligoclonal bands, and a raised level of lysozyme. MRI revealed multiple contrast-enhanced granulomas at the base of the brain with partial involvement of diencephalic and mesencephalic structures and parts of the spinal cord. There was no evidence of systemic manifestation of sarcoidosis. Administration of corticosteroids led to improvement of the symptoms.